Iris metastasis as the initial presentation of metastatic esophageal cancer diagnosed by fine needle aspiration biopsy: A case report

Abstract

Rationale: Metastasis of neoplasms to the eye is quite uncommon. In this case report, we describe a patient where primary esophageal cancer was diagnosed by fine needle aspiration biopsy (FNAB) of an iris tumor.

Patient concerns: A 70-year-old male complained of redness and discomfort in the right eye.

Diagnosis and interventions: The patient's right eye was diagnosed as idiopathic uveitis, and a topical steroid was administered. As vitreous opacities were observed even after topical therapy, oral prednisolone was administered. On slit-lamp examination of the right eye, an iris mass with neovascularization was seen in the anterior chamber. A metastatic tumor was suspected, and FNAB was performed. Histology revealed squamous cell carcinoma. Systemic workup revealed esophageal cancer with several metastases. Best-corrected visual acuity decreased to 20/400, and intraocular pressure was 40 mmHg in the right eye. Two iris tumors with neovascularization were present extending into the anterior chamber with posterior iris synechiae and 360 degree peripheral anterior synechiae. Intraocular pressure in the right eye was medically managed with hypotensive eye drops and oral acetazolamide. Iris metastases were treated with 40 Gray of radiation therapy and concurrent chemotherapy.

Outcomes: The tumor regressed, but intraocular pressure was refractory to treatment because of 360 degree goniosynechial closure. The right eye lost light perception six months after treatment commenced, and the patient died 9 months after the onset of therapy due to multiple systemic metastases.

Lessons: This is a rare case of masquerade syndrome without systemic symptoms in which FNAB of an iris tumor led to a diagnosis of metastatic esophageal squamous cell carcinoma. Although the patient lost his sight due to uncontrollable ocular hypertension, systemic chemotherapy, and radiation therapy were initially effective in the treatment of the metastatic iris tumor. As the prognosis of patients with metastatic iris tumors is poor, it is important for ophthalmologists to consider such diagnoses and conduct systemic investigations when necessary.

Figure 1

The anterior chamber images of iris tumor. (A) An image of the anterior segment of the right eye. There was a tumor located on the iris from 4 to 7 o’clock (arrow). (B) A magnified image of Figure 1A. Neovascularization occurred in the tumor. (C) An image of anterior segment optical coherence tomography. The angle was partially occupied by the tumor (arrow). (D) The technique of the fine-needle aspiration biopsy for iris tumors.

Figure 2

Histopathology and immunohistochemistry of biopsied iris tumor. (A) Squamous cell carcinoma (arrow) was identified in the tumor. The tumor cells are distributed as single cells or as small cellular aggregates. Atypical epithelial cells varied from eosinophilic to amphophilic and showed a polygonal shape with abundant cytoplasm. Keratinization was prominent, and the borders of cells were clearly identified, with intercellular bridges. In the atypical epithelial cells, the nuclear shape was oval to irregular, in which nuclear bodies were prominent, and there was increased chromatin. The size of the nucleus varied, and some cells had multiple nuclei (arrow, hematoxylin-eosin stain, ×200). (B) Histopathology of the biopsied esophagus. Tumor cells with an alveolar configuration proliferated profusely (arrow), in which cell division and amorphous nuclei and abundant cytoplasm were observed (hematoxylin-eosin, ×200).

Figure 3

The iris metastasis was diminished after combined therapy. (A) An image of the anterior segment of the right eye. In the anterior chamber, whitish masses with neovascularization located at 9 o’clock and from 2 to 8 o’clock (arrow) were accompanied with posterior synechiae (Three and a half months after initial treatment). (B) An image of the anterior segment of the right eye after chemotherapy and radiation therapy. Therapy effectively diminished iris tumor volume (arrow), except for posterior synechiae (6.5 after initial treatment).